C. A. Thiels1, J. M. Nienow1, T. M. Lal1, J. M. Aho1, K. S. Pasupathy1, T. I. Morgenthaler1, R. R. Cima1, R. C. Blocker1, S. Hallbeck1, J. Bingener1 1Mayo Clinic,Rochester, MN, USA
Introduction: National Quality Forum never events continue to occur despite highly trained teams following procedures designed to avoid these harms. We report the first prospective analysis of human factors contributing to surgical and procedural never events using a rigorous, validated Human Factors Analysis and Classification System (HFACS).
Methods: From 8/2009 – 12/2013 all surgical and procedural never events (i.e. retained foreign object (RFO), wrong site/side procedure, wrong implant, wrong procedure) underwent systematic error causation analysis by a team consisting of the patients’ care providers, patient safety specialists, and surgical leadership as soon as the event was discerned. During the root-cause analysis meeting, contributing human factors were categorized using HFACS. Factors were analyzed according to incident type and Reason’s 4 levels of error causation (actions, organizational influences, supervision, preconditions for actions). The causes were further categorized into subgroups (e.g. action into compliance versus error; error into decision or perception based) and finally into one of 159 subcategories of contributing factors (e.g. confirmation bias, communication failure), termed nano-codes.
Results: During the 4.5 year period over half a million procedures were performed and 62 never events were evaluated using HFACS. Concurrent with counter measures the event frequency decreased from 2010 to 2013. A total of 603 contributing nano-codes were identified, grouped by four major error causes (Table 1). The relative contribution of identified error causes to each type of never event revealed that actions (n=251) and preconditions to actions (n=281) accounted for the majority of the nano-codes across all four types of never events. The most common action nano-codes were ‘failed to understand’ (n=33, decision error) and ‘confirmation bias’ (n=32, perception error). The most commonly coded pre-condition nano-code was ‘channeled attention on a single issue’ (n=28, cognitive factor) and ‘inadequate communication’ (n=25, team resource management). As subgroups, cognitive factors, decision errors, technology and communication predominate as underlying causes to surgical and procedural never events.
Conclusion: To our knowledge, this is the first report of a validated human factors analysis applied prospectively to surgical and procedural never event review. Targeting interventions to address cognitive factors and team resource management as well as perceptual biases may reduce decision errors and will likely be most successful in further improving patient safety. The results delineate targets to further reduce never events from our healthcare system.
